Laparoscopy-assisted ventriculoperitoneal shunt surgery: personal experience and review of the literature

Abstract

Ventriculoperitoneal shunting is a widely accepted technique for the treatment of hydrocephalus. The standard procedure to insert the peritoneal catheter requires an abdominal incision, muscle dissection, and opening of the peritoneum. A number of complications related to the abdominal surgical phase have been reported. Laparoscopy-assisted ventriculoperitoneal shunting is a valid alternative procedure that reduces surgical trauma. We describe our experience and review the literature. A total of 30 laparoscopically guided ventriculoperitoneal shunting procedures were performed between January 2007 and June 2008, in collaboration with a general surgeon experienced in laparoscopy. Of these procedures, 25 were new shunt placements and 5 were revisions. Data about operative time, outcome, and complications were registered and compared with a group of 30 patients treated by means of standard laparotomy in the period 2005-2007. Laparoscopic shunt placement was successful in all patients. Operative duration, complications, and postoperative pain were all lower in patients treated by laparoscopy as compared to the laparotomy. In the laparoscopic group, an earlier peristalsis, quicker mobilization, and better cosmetic results were also noted. Laparoscopy in both ventriculoperitoneal shunt placement and revision is a safe, effective, and minimally invasive technique. It ensures proper abdominal placement of the distal catheter under direct vision allowing confirmation of its patency.

Incisional hernia after ventriculoperitoneal shunt

“…With its advantage of better vision and less tissue trauma, laparoscopic placement of the abdominal end of the shunt is rapidly becoming accepted as a procedure of choice, and has reportedly brought down the incidence of complications at the distal end [3,4,6,[8][9][10]. In addition, laparoscopic placement of the shunts allows for confirmation of shunt patency and function by direct visualization of CSF flow from the shunt tubing [10].…”

“…The advantages of the laparoscopic approach also include a shorter hospital stay, less post-operative pain, lower chance of incisional hernia formation, and, since the catheter is positioned under direct vision with minimal bowel manipulation, there is a much lower chance of bowel injury and adhesion formation [6,8]. Even when dealing with complications, laparoscopy offers a distinct advantage over laparotomy, especially in terms of superior visualization of the peritoneal cavity, retrieval of displaced shunts, lysis of adhesions, culture of abdominal fluid, repositioning of displaced tubings, and assessing the abdomen for any other pathology [2][3][4]6,8,10]. However, the flip side is that separate incisions (for port and shunt placement) as well as two separate teams (neurosurgical and laparoscopic) are required, which may not be available everywhere.…”

“…Complications that occur at the distal (abdominal) end are also a cause of significant morbidity, and in various series, nearly 5 -47 % of all shunt failures are thought to be due to malfunction of the distal catheter [4][5][6][7] with a higher incidence in patients with scoliosis, obesity and those who have undergone prior abdominal surgery [4,8]. Abdominal complications that have been reported are; shunt infection, development of an inguinal hernia, subcutaneous collections of CSF, peritoneal or omental cyst formation, mesenteric pseudotumors, bowel perforation, intestinal volvulus around the shunt tubing, catheter disconnection; and various types of catheter migrations such as extraperitoneal retraction and displacement, migration of the catheter into the pleural cavity or heart, or protrusion of the catheter through the mouth, umbilicus, bladder, vagina, anus, or scrotum.…”

“…Abdominal complications that have been reported are; shunt infection, development of an inguinal hernia, subcutaneous collections of CSF, peritoneal or omental cyst formation, mesenteric pseudotumors, bowel perforation, intestinal volvulus around the shunt tubing, catheter disconnection; and various types of catheter migrations such as extraperitoneal retraction and displacement, migration of the catheter into the pleural cavity or heart, or protrusion of the catheter through the mouth, umbilicus, bladder, vagina, anus, or scrotum. Knotting of the shunt has also been reported on occasion [1][2][3][4][5][6][7], as have been other less common complications such as adhesive bowel obstruction, intra-abdominal abscesses, cerebrospinal-enteric fistula and intractable CSF ascites [1,3].…”

Development of the Metronomic Biofeedback Pump for leptomeningeal carcinomatosis: technical note

“…A 4-wavelength spectrophotometer (355, 365, 395, and 470 nm) is used to determine concentrations of MTX in CSF in real time, based on the characteristic ability of MTX to absorb ultraviolet light at 370 nm. 20 The 4-wavelength spectrophotometer has been tested and is shown to be effective in monitoring MTX concentrations in real time. This will measure the distribution and elimination of drugs, and enable physiological feedback on treatment response.…”